In February 1994, Ms. Sampson's emphysema was causing shortness of breath, which limited her activities. I advised her to call if her respiratory symptoms worsened. Two days later, she did. I saw her in the office, began treatment with oral steroids, advised an increase in her rescue β2-agonist inhaler, and started antibiotic treatment.

The next morning she was worse. I advised her to go to the emergency department and asked our practice staff to fax over information. I arrived after the emergency department staff had seen her and reviewed films and blood gas results that revealed an increasing Pco2. Consulting with the emergency department staff, we concurred that she should be hospitalized. I completed her history and physical, talked with nurses and residents on the floor, added faxed office notes to her record, began intravenous steroids, and let her know I would return in the morning. Before leaving, I listened to her husband's concerns. He felt responsible that his wife smoked until 3 years before. I reminded him that we both did a lot to help her quit. I told him that after her discharge, I would arrange to see Ms. Sampson in our office for her follow-up care.